Stricter California Vax Laws Have Worked ... So Far

— But some argue for national vaccination exemption policy

California's tighter vaccination laws were associated with a decline in the rate of kindergarteners who were not up-to-date with vaccines, researchers found.

The rate of kindergarteners who had missed required vaccinations fell from 9.84% in 2013 to 4.83% in 2017, following an educational campaign and two laws, including the 2016 legislation that eliminated personal belief exemptions, reported S. Cassandra Pingali, MPH, of Emory University in Atlanta, and colleagues.

There was also a substantial drop in the percentage chance of within-school contact among kindergarteners without up-to-date vaccination status -- from 26.02% in 2014 to 4.56% (95% CI 4.21%-4.99%) in 2017, the authors wrote in JAMA.

However, medical exemption rates rose during the study period -- from 0.19% in 2013 to 0.73% in 2017, the authors noted.

These findings align with new state data showing a 70% increase in kindergarteners who had obtained medical exemptions from vaccines in the 2018-2019 school year compared to 2 years ago when the law eliminating non-medical exemptions took effect. This included large concentrations of exemptions in more affluent parts of the state. So far, there have been 55 measles cases in California in 2019, the Los Angeles Times reported.

California has been tightening its stance on vaccinations for several years, including prior to the Disneyland measles outbreak in 2015, Pingali and colleagues noted.

In 2014, California still had a personal belief exemption, but Assembly Bill 2109 (AB 2109) "required parents to submit proof they had discussed the risk of not vaccinating their children with a healthcare practitioner" before obtaining this exemption, the authors said. They added that the California Department of Public Health and local health departments then initiated a campaign to inform schools "on the proper application of the conditional admission criteria, which allow students additional time to catch up on vaccination" in 2015. This was prior to 2016 and Senate Bill 277 (SB 277), which banned personal belief exemptions altogether.

Currently, SB 276 is pending in the California legislature, which would allow public health departments to look more closely at medical exemptions granted by doctors. The bill has passed the California State Senate, and Gov. Gavin Newsom (D) said he will sign it if it reaches his desk, according to Kaiser Health News, which reported Tuesday on an ongoing investigation by the state's medical board into physicians who have granted large numbers of medical exemptions.

For this study, Pingali and colleagues examined effects of AB 2109 and SB 277 as well as the 2015 educational campaign, by looking at rates of kindergarteners in California schools who did not have all required vaccinations from 2000 to 2017.

During this time, over 9.3 million kindergarteners entered 10,391 California schools, including almost 722,000 kindergarteners without up-to-date vaccination status. Following these laws and educational efforts, clusters of schools with high rates of kindergarteners lacking complete vaccination status also fell -- from 124 clusters with 3,026 schools in 2012-2013 to 110 clusters with 1,613 schools (95% CI 1,565-1,691) in 2016-2017.

In addition to medical exemptions, the Times article also cited an increase in home-schooled children, who are not required to be vaccinated. Indeed, Pingali and colleagues found that the rate of kindergarteners not subject to immunization requirements increased from 0.46% in 2016 to 1.08% in 2017.

'Social Justice, Not Parental Choice'

An accompanying editorial by Matthew Davis, MD, and Seema Shah, JD, both of Northwestern University Feinberg School of Medicine in Chicago, proposed that it might be time for "a unified national approach" to exemptions for required childhood vaccines to replace the varied state laws.

They cited "federal precedents" that have made vaccination a national matter, such as the CDC's Advisory Committee on Immunization Practices (ACIP), the Vaccines for Children program, and the National Childhood Vaccine Injury Act.

There could be a range of options for this type of national system for exemptions, Davis and Shah noted -- from eliminating all non-medical exemptions to only allowing non-medical exemptions for vaccines other than the measles, mumps, and rubella (MMR) vaccine.

Davis and Shah said that arguments to preserve non-MMR exemptions focus on abiding by the "ethical and legal constraints that public health interventions should involve the least possible restriction on liberty." But the editorialists argued that there is "a compelling justification" to require measles vaccination due to both the "highly contagious, severe and common" nature of measles and the "safe and durably effective" vaccine.

"Parental liberty is not absolute but constrained by the duty to protect children, which is particularly salient amid increasing numbers of cases of measles and other vaccine-preventable illnesses," they wrote. "As the U.S. Supreme Court explained [in a 1944 case], 'The right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death.'"

"Some scholars have submitted that childhood vaccination is a matter of social justice, not parental choice," the editorialists noted.

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